Advantages in orthopedic implant infection diagnostics by additional analysis of explants

Advantages in orthopedic implant infection diagnostics by additional analysis of explants | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Advantages in orthopedic implant infection diagnostics by additional analysis of explants Arnold J Suda, Thomas Miethke, Nadine Landua, Udo Obertacke This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5318175/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Purpose Implant-associated infections are the most challenging complication in orthopedics and trauma surgery as they often lead to long courses of illness and are a financial burden for the healthcare system. There is a need for fast, simple, and cheap identification of pathogens but the ideal detection method was not found yet. The work aims to test whether the detection of pathogens culturing the removed implant is more successful than from simultaneously taken tissue samples or punction fluid. Methods Implants were removed due to infection, irritation, or loosening. Tissue samples and joint fluids were processed for bacterial growth in sterile conditions. Samples were incubated and checked for growth. Bacterial identification and antibiotic sensitivity testing were performed. Data were anonymized, and statistical analysis was done using Excel and SAS, employing tests like Shapiro-Wilk, Mann-Whitney-U, and Kruskal-Wallis. Ethical approval was obtained for this study. Results Between February 2018 and April 2019, a total of 163 patients (175 cases) underwent orthopedic implant removal for various reasons. 30 cases were not usable or analyzable due to missing or damaged reference material, so 145 cases could be evaluated due to study protocol. The range of detected bacteria was as expected and included low-virulent bacteria such as Micrococcus luteus and Corynebacteria . Pathogen detection by culture of the the explant´s was more sensitive (84.83%) than pathogen detection from tissue samples and punction fluid (64.14%, p<0.0001). Comorbidities did not play any role in the quality of detection but prior antibiotic treatment did influence the results of tissue diagnostics. Conclusion This study showed with a higher frequency of bacterial detection of orthopedic explant´s surface compared to tissue samples or punction fluid. This may reduce the number of samples and cost but enhances the quality of orthopedic implant-related infection diagnostics. orthopaedic implant infection diagnostics implant surface implant removal Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Orthopedic implants are removed for several reasons such as infection, pain, or mechanical issues. Infection is a main cause but there is a high number of occult and low-grade-infection which are difficult to find. Detection of bacteria after orthopedic implant removal can be influenced by prior antibiotic treatment and the methods used for it. As treatment of orthopedic implant-related infection (OII) is not rare but expensive and harms patient´s quality of life, fast and correct diagnosis and treatment are crucial [ 1 – 4 ]. Infection after orthopedic implant implantation can be caused by perioperative contamination, hematogenous infection, or per continuitatem [ 5 – 7 ]. Biofilm on the implant´s surface is often present [ 8 , 9 ]. Different classification systems define acute and chronic infections [ 8 , 10 , 11 ]. There are many known risk factors for OII, such as comorbidities, prolonged operation time, smoking, and revision surgery [ 9 , 10 , 12 – 18 ]. Coagulase-negative staphylococci such as Staphylococcus epidermidis , part of the natural skin microbiome, are often causal for orthopedic implant-related infections. If they occur in joints or on implants, they are pathogens [ 6 ]. Together with Staphylococcus aureus , coagulase-negative staphylococci are responsible for 50% of OII [ 5 ]. The other 50% are caused by Streptococci, Enterococci , Gram-negative rods, anaerobes, Candida , and rare pathogens [ 6 ]. The presence of low-virulent bacteria such as coagulase-negative staphylococci,, anaerobe Cutibacterium (Propionibacterium) acnes , and Gram-positive Corynebacteria are often caused by contamination and may lead to a chronic condition and slow development of infection. High-virulent bacteria such as Staphylococcus aureus, Escherichia coli , and Streptococci may lead to early and fulminant infection up to sepsis [ 6 , 19 ]. In 10–30%, multiple bacteria with a minimum of two pathogens are detected [ 5 ]. Biofilm of the implant´s surface is the main cause of bacterial infection [ 3 , 20 ]. A matrix of extra-cellular polymer substances (EPS) surrounds the implant and safes bacteria from antibiotics and the body´s defense cells [ 3 , 21 , 22 ]. There are different options for diagnosing OII [ 2 ]: detection of bacteria from peri-implant tissue and punction fluid (in joints), whereas swabs don’t play a role in diagnostics anymore [ 23 ]. False-negative results may occur in the case of prior antibiotic treatment [ 24 , 25 ]. Three to five tissue samples should be taken from representative locations and incubated for up to ten days [ 5 , 26 , 27 ]. In the case of the presence of low-virulence pathogens, one single positive result may be interpreted as contamination [ 2 , 5 ]. Multiplex-polymerase chain reaction (PCR) may offer new options but are not in extensive use until now [ 2 , 28 , 29 ]. Detection of the biofilm´s pathogens is promising and sonication of the explant is also used to detect not only planktonic bacteria as in tissue but metabolic inactive bacteria of matrix-secured biofilm but is expensive, not available in all hospitals and challenging in logistics for specimen transport [ 2 , 30 ]. The best method for extraction and quantification of biofilm bacteria has not been found yet [ 31 – 34 ]. This study aimed to evaluate if pathogen-detection by culturing of explants with conventional microbiological methods and without sonication is superior to detection by culture of tissue and punction fluid. Finding a correlation between clinical infection and microbiological results using the methods described was not the aim of this study. Materials and Methods Implants were removed for different reasons such as infection, irritation, aseptic loosening. Removal of implant, harvesting of tissue from representative areas, and punction fluid in hip, knee, and shoulder joints was performed by the surgeon according to the study protocol. The hospital´s database was used for anonymized patient data, and comorbidities and other risk factors were evaluated. The explant was put in a sterile tube (Falcon, Fisher Scientific, Fig. 1 ) and transferred to the microbiological institute within one hour. The sterile tube was filled with nutrient broth Schaedler Broth + Vit. K3 13 ml (bioMérieux SA) at the safety cabinet (HERASAFE2025, Thermo Scientific). The tube was transferred to the incubator HettCube 600 (Hettich) and incubated for ten days. The medium was checked daily and in case of haze seeded to an aerobe agar plate (BIO-RAD Chocolat agar PVS) and Schaedler-Agar (bioMérieux SA) for detection of anaerobe. If there was no haze after ten days, the fluid was seeded on the agars as described above and the aerobe agar was incubated for 48 hours in CO 2 -incubator HERAcell240i (Thermo Scientific), the anaerobe plate was placed in an Oxoid AnaeroGen 2.5 l bag (Thermo Scientific) with an Oxoid Resazurin-Anerobic-Indicator (Thermo scientific). In the case of bacterial growth, the bacterium was identified and its antibiotic sensitivity was determined using the automatic Vitek 2 (bioMérieux SA) system. A tissue probe was placed in a sterile tube (ProbeAX, Axon Lab, Fig. 2 ) with NaCl and ten small steel balls to chop the tissue in the dispersant IKA ULTRA TURRAX (Tube Drive). The chopped tissue was struck on three aerobe agar plates (blood agar (Fisher Scientific), BIO-RAD Chocolat agar PVS, and Mac-Conkey-Agar (bioMérieux SA)) under a safety cabinet (HERASAFE2025). In addition, two anaerobe agar plates were used (Schaedler-Agar (bioMérieux SA) and Schaedler-Kanamycin-Vancomycin-Agar (bioMérieux SA)). The material was also placed in an anaerobe Schaedler Broth + vit. K3 nutrient broth (13 ml, bioMérieux SA), the rest was inoculated in an aerobe Brain Heart Infusion Broth (9 ml, bioMérieux SA). Blood agar and Mac-Conkey-Agar were incubated in a HettCube 600 (Hettich) for 24 hours. The chocolate agar was incubated in a CO 2 -incubator HERAcell240i (Thermo Scientific). After 24 hours, aerobe agar plate growth was evaluated. In the case of growth, the bacterium was identified and its antibiotic sensitivity determined. Mac-Conkey-agar was discarded if there was no growth after 24 hours. Chocolate agar was incubated for 10 days in the CO 2 -incubator HERAcell240i (Thermo Scientific) and the case of no growth discarded. Identification of bacteria and antibiotic sensitivity testing was done with Vitek 2 (bioMérieux). Anaerobe agar plates were put in 2.5-liter boxes filled with Oxoid AnaeroGen and Oxoid Resazurin-Anaerobe-Indicator (Thermo Scientific) and checked after 48 hours, 4, 7, and 10 days. Aerobe plates were checked after 24 hours, 48 hours, 4, 7 and 10 days. In case of no bacterial growth after 10 days, a final seed in a Schaedler- and chocolate agar was done for 48 hours. The punction of fluid was transported in a Falcon tube (Fisher Scientific) and centrifugated using Heraeus Megafuge 16 (Thermo Scientific). With the sediment, a gram stain was performed using Previ Color Gram (bioMérieux). Microscopic observation of the Gram preparations was carried out using a Nikon Eclipse Ci microscope. Parallel to the preparation of each Gram preparation, parts of the punctate were inoculated onto three aerobic plates under the safety cabinet (HERASAFE2025, Thermo Scientific): blood agar (Fisher Scientific), chocolate agar (BIO-RAD Chocolat agar PVS) and Mac-Conkey agar (bioMérieux SA). Two more anaerobic agar plates were added: Schädler agar (bioMérieux SA) and Schaedler kanamycin-vancomycin agar (bioMérieux SA). Another part of the punctate was added to an anaerobic Schaedler Broth + vit. K3 nutrient broth (13 ml, bioMérieux SA) and another part was transferred to an aerobic liquid medium: Brain Heart Infusion Broth (9 ml, bioMérieux SA). The blood agar and Mac-Conkey agar were placed in the HettCube 600 incubator (Hettich) for 24 hours. The chocolate agar was placed in the HERAcell240i CO 2 incubator (Thermo Scientific) from the beginning. All aerobic agar plates were read after 24 hours. If aerobic germs had already grown after this period, bacteria were identified and their antibiotic sensitivity determined. The Mac-Conkey agar plate was discarded if no growth was observed after 24 hours. If no growth was seen on the blood agar plate, this plate was also placed in the HERAcell240i CO 2 incubator. The blood agar and the cooked blood agar were then incubated in the CO 2 incubator for up to ten days. If germs had grown during this period, this was also followed by identification and resistance testing. The anaerobic agar plates were incubated as described above. The aerobic plates of the analyzed punction fluids were also checked regularly: After 24 hours, 48 hours, four days, seven days, and ten days respectively. The anaerobic plates were examined for the first time after 48 hours, then also after four days, seven days, and ten days - in the same way as the biopsy specimens. If microbial growth was detected at any of these points in time, bacteria were identified and their antibiotic sensitivity determined as described above. To rule out contamination of the sample containers, 19 empty sample containers were explored for bacterial growth. No bacterial growth was detected in any of these sample containers. This ensured that bacteria could only be detected by the respective sample material, i.e. from the metal explant, the tissue sample, or the punctate. We obtained a positive vote from the local ethical committee (2018 618N MA). Statistical analysis was performed with the help of the Institute of Medical Statistics/Heinrich-Lanz-Center of Medical Faculty Mannheim with the use of Excel® 2019 (Microsoft) and SAS (Version 9.4 (SAS Institute, Inc., Cary, North Carolina). Shapiro-Wilk-test was used for age distribution, comparison of two different groups was performed with the Mann-Whitney-U-test. More groups were assessed using the Kruskal-Wallis test. The chi²-test was used for qualitative testing, exact Fisher-test for calculation of contingency tables and significance. α = 0.05 was determined as significant. Results Between February 2018 and April 2019, 175 consecutive cases (163 patients, 89 females, 86 males, mean age 62.1 years, range 16 to 89) were included in this prospective study with the removal of orthopedic implants in a single university trauma center in Germany. Indication for implant removal was an infection in 64 cases (36.6%), loose implant in 50 cases (28.6%), irritation and painful implant in 33 cases (18.9%), and patient´s wish in 16 cases (9.1%) (Fig. 3 ). 52 patients (29.7%) had been treated with implant-related infection before removal, and another 29 patients (16.6%) needed inpatient treatment for infection. Patients showed several comorbidities: 97 patients (55.4%) had hypertonia, 35 patients (20%) had coronary disease, and 23 patients (13.1%) had diabetes as the main comorbidities. Tumor disease (13.1%), kidney failure (10.9%), obesity (6.9%), osteoporosis (6.3%), and rheumatoid disease (4.6%) were other comorbidities identified. Most patients had more than one comorbidity. 113 patients (64.6%) had no signs of infection in blood cell count (CRP < 5mg/l and white blood cells < 10000/µl) at the time of surgery. 89 implants (51.4%) have been removed from the femoral region, 42 (24.3%) from the lower leg region, and 18 (10%) in the spine region. 10 implants (5.8%) were removed from the humerus, 8 (4.6%) from the forearm and 6 (3.5%) from the pelvis. In 2 cases, the exact region was unclear due to unclear documentation of removal between the two regions. The authors decided to define the region according to the surgical report. In 148 cases (84.6%), no bacteria could be detected before implant removal, in 61 cases (34.9%), antibiotic treatment was administered before surgery (Table 1). 25 patients (14.3%) had one revision surgery before implant removal, and another 32 patients (18.3%) had two or more surgeries. 30 (17.1%) of 175 specimens could not be fully evaluated according to the study protocol (155 cases with tissue/punction fluid, 165 cases with explants): in 10 cases, the transport box of the explant was damaged and in 20 cases, punction fluid was not enough for evaluation or not taken so the comparison was impossible. Overall, 145 cases were included in the study with explant, tissue, and punction fluid. In 46 cases (31.7%), no bacteria could be detected. 71 of 145 cases (49.0%) showed the same bacteria in both tissue and explant´s surface. With tissue and punction fluid alone, bacteria could be detected in 91 cases (62.8%), on explant´s surface alone, bacteria could be detected in 96 cases (66.2%, p < 0.001, tissue/punction fluid compared to explant´s surface). In 41 cases (28.3%), bacteria could only be detected from the explant´s surface whereas this was only the case in 11 cases (7.6%) of tissue/punction fluid (Fig. 4 , p < 0.001, explant´s surface compared to tissue/punction fluid). In another 22 cases, additional bacteria could be detected from explant´s surface or tissue/punction fluid (11 and 11, respectively). 25 cases (36.5%) showed same bacteria throughout all examination methods: in 123 cases (71 + 41 + 11 = 84.83%), detection of pathogens from explant´s surface was equal or superior compared to tissue and punction fluid (93 cases, 71 + 11 + 11 = 64.14%, p < 0.0001, explant´s surface compared to tissue/punction fluid). The spectrum of organisms detected is provided in Table 2. Staphylococcus epidermidis, S. aureus and E. faecalis were most commonly detected by all diagnostic methods used (Fig. 5 ). Figure 6 shows only the additional detected organisms unraveled by the method used in patients with multiple bacteria detected, Fig. 7 shows the single detected organisms particular by each method. Age, sex, reason for surgery, type of implant or hypertonia, and original diagnosis for implantation or other comorbidities did not show statistically significant influences on results (p > 0.05, respectively). In cases with or without antibiotic treatment before surgery, bacteria could be detected in tissue/Punction fluid in 11.6% and 14.8% in cases without antibiotic treatment (Table 1, p = 0.0001). In cases with or without antibiotic treatment before surgery, bacteria could be detected in explant´s surface in 23.0% and 35.2% (p = 0.071). In this collective, antibiotic treatment before surgery had a statistically significant influence of detection of bacteria of tissue or punction fluid but not of explant´s surface. The differences in detection between tissue/punction fluid and explants´s surfacewere statistically significant (p = 0.0001). Discussion In this study, the detection of bacteria of orthopedic explant´s surface showed significantly higher sensitivity (84.8%) compared to tissues or punction fluid (64.1%). Treatment of orthopedic implant-related infections is challenging for both patient and surgeon as well as expensive [ 3 ]. Fast and correct detection of bacteria causing the infection is crucial for correct treatment, independent of age or comorbidities [ 9 , 12 , 18 , 35 ]. In this study, the reasons for the implantation and explantation of orthopedic implants were multifaceted, similar to other studies [ 5 ]. In this study, no differences in the detection of bacteria were seen regarding comorbidities [ 12 – 18 , 36 – 43 ]. A broad range of pathogens could be identified, the spectrum was similar to other studies: In a study of Corvec et al., coagulase-negative Staphylococci were identified as the most common pathogens in OII [ 5 , 44 ]. Multiple bacteria are present from 10 to 30%, revision surgery and longer operation times are suspected main reasons [ 6 , 19 ]. In our study, Corynebacterium was identified as a rare pathogen in OII, similar to Holinka et al. [ 45 ]. Micrococcus luteus and Stenotrophomonas maltophilia were detected quite often in the explant´s biofilm. The presence of these was described before in patients with rheumatoid disease and immune-suppressive therapy [ 46 ]. Micrococcus luteus was described as a non-pathogenic bacteria but not previously discussed as a pathogen in OII. It remains uncertain if the presence of Micrococcus luteus on the implant´s surface has any clinical impact. No pathogens could be detected in many patients in our collective because these patients received orthopedic implant removal for other reasons than infection. Linking clinical findings and the presence of infection to microbiological diagnostic methods was not the aim of this study. Font-Vizcarra et al. showed that swabs are not suitable for OII diagnostics, their only advantage is the low cost [ 23 , 28 , 47 ]. Trampuz et al. compared the diagnostics of sonication fluid with tissue and showed higher sensitivity compared to tissue (79%, and 61%, respectively) [ 28 , 30 ]. Because of costs and the complexity of transport and procedure, sonication is not available in all hospitals [ 29 , 47 ]. Portillo et al. showed higher sensitivity of multiplex-PCR compared to sonication but this procedure is also expensive and did not become standard procedure so far as there is a high risk of contamination and false positive results [ 48 ]. In a prior study, the author of this study showed a high negative but low positive predictive value in OII – diagnostics using multiplex-PCR [ 49 ]. Today, the gold standard for OII diagnostics remains 3 to 5 tissue samples and conventional microbiological methods [ 2 ]. More samples could lead to more false-positive results because of contamination [ 50 ]. Reasons for negative results may be prolonged transport to the microbiological lab, too short incubation time, prior antibiotic therapy, or low-virulent pathogens [ 7 ]. In our study, all samples were transported immediately within hours to the lab and all samples were incubated for 10 days. Low-virulent and slow-growing pathogens can be detected safely using this technique [ 6 ]. Schäfer et al. described only 74% of bacteria detection in the first seven days, and other bacteria up to ten days, so we decided on ten days in our study [ 25 ]. We could see a statistical significance of prior antibiotic therapy and diagnostic results of tissue and punction fluid in our collective, similar to Flesch et al. [ 7 ]. Our results support the theory that biofilm diagnostic is superior to tissue. In 35.9%, we detected more pathogens in biofilm compared to tissue and punction fluid, which was seen before [ 2 ]. One reason may be the biofilm protection for antibiotic therapy which is not present in tissue samples [ 2 , 21 , 22 ]. Antibiotic treatment should be initiated immediately in case of acute infection and not delayed until samples can be taken which is not recommended in chronic infection [ 19 , 25 , 51 ]. In 15.2% (22 cases), pathogens could only be shown in tissue or punction fluid. Contamination with skin or absence of biofilm may be the main reason for this as published before [ 30 ]. In 84.8%, the explant´s surface showed pathogens – in 64.1%, tissue and punction fluid showed pathogens - in 49.0%, both explant´s surface and tissue showed pathogens (p < 0.001, respectively) which supports our hypothesis that diagnostic of explant´s surface fluid is superior to tissue and/or punction fluid. Instead of up to 5 samples, one sample of explant´s surface may be enough for safe and correct diagnostics which reduces costs and spares resources [ 4 ]. This study has several limitations: First, this study was performed in a single center in Germany. An international multiple-center study could lead to the detection of different pathogens and different results. Second, the study sample was relatively small, a larger sample size could also lead to different results. Third, co-morbidities were evaluated according to electronic patient data: missing or wrong information may have influenced our results with no statistically significant influence of any co-morbidity. Fourth, no comparison to other methods such as sonication or PCR and no correlation to clinical infection was performed: this could be the topic of the next study in a multi-centric setting. Fifth, employees of the microbiological institute knew about this study – this may have biased the results or the methods of their work but this was mandatory due to the ethical committee vote. An advantage was the diagnostics at one single center with the same procedures and machines. Sixth, the pooling of five tissue samples may also reduce costs but would not identify as many pathogens as explant´s surface. Lastly, only English and German publications were included in the literature research. In summary, our study supports the hypothesis that pathogen diagnosis of orthopedic explant´s surface using incubation of the transport fluid is superior compared to tissue samples. Now that this method is proven to be functional, cheap, and safe, future multiple-center studies considering the clinical status as well may support the findings of our present study. Declarations Compliance with Ethical Standards Human Ethics and Consent to Participate declarations: not applicable. Funding No funding was obtained for this study. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Nadine Landua and Arnold Suda. The first draft of the manuscript was written by Nadine Landua and Arnold J Suda and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.Conceptualization: Arnold J Suda; Methodology: Thomas Miethke, Udo Obertacke, Arnold J Suda; Formal analysis and investigation: Nadine Landua; Writing - original draft preparation: Nadine Landua and Arnold J Suda; Writing - review and editing: Arnold J Suda, Thomas Miethke, Udo Obertacke; Resources: Thomas Miethke, Arnold J Suda; Supervision: Arnold J Suda, Thomas Miethke, Udo Obertacke. References Darouiche RO (2004) Treatment of infections associated with surgical implants. N Engl J Med 350:1422–1429. 10.1056/NEJMra035415 Renz N, Muller M, Perka C, Trampuz A (2016) [Implant-associated infections - Diagnostics]. Chirurg 87:813–821. 10.1007/s00104-016-0234-x Arciola CR, Campoccia D, Ehrlich GD, Montanaro L (2015) Biofilm-based implant infections in orthopaedics. Adv Exp Med Biol 830:29–46. 10.1007/978-3-319-11038-7_2 Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J (2012) Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 27:61–65 e61. 10.1016/j.arth.2012.02.022 Renz N, Perka C, Trampuz A (2016) [Management of periprosthetic infections of the knee]. Orthopade 45:65–71. 10.1007/s00132-015-3217-6 Winkler T, Trampuz A, Hardt S, Janz V, Kleber C, Perka C (2014) [Periprosthetic infection after hip arthroplasty]. Orthopade 43:70–78. 10.1007/s00132-013-2132-y Flesch I, Arnscheidt C, Ihle C (2017) Spätinfekt in der Endoprothetik. OP-JOURNAL 33:142–148 Trampuz A, Zimmerli W (2006) Diagnosis and treatment of infections associated with fracture-fixation devices. Injury 37 Suppl 2S59–66. 10.1016/j.injury.2006.04.010 Perka C, Haas N (2011) [Periprosthetic infection]. Chirurg 82:218–226. 10.1007/s00104-010-2014-3 Barrett L, Atkins B (2014) The clinical presentation of prosthetic joint infection. J Antimicrob Chemother 69(Suppl 1):i25–27. 10.1093/jac/dku250 Zimmerli W (2014) Clinical presentation and treatment of orthopaedic implant-associated infection. J Intern Med 276:111–119. 10.1111/joim.12233 Bozic KJ, Lau E, Kurtz S, Ong K, Berry DJ (2012) Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 470:130–137. 10.1007/s11999-011-2043-3 Chen JY, Lo NN, Chong HC, Bin Abd Razak HR, Pang HN, Tay DK, Chia SL, Yeo SJ (2016) The influence of body mass index on functional outcome and quality of life after total knee arthroplasty. Bone Joint J 98–B:780–785. 10.1302/0301-620X.98B6.35709 Peersman G, Laskin R, Davis J, Peterson M (2001) Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res :15–23 Dowsey MM, Choong PF (2009) Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res 467:1577–1581. 10.1007/s11999-008-0551-6 Iorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL (2012) Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty 27:726–729e721. 10.1016/j.arth.2011.09.013 Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH (2007) Does excessive anticoagulation predispose to periprosthetic infection? J Arthroplasty 22:24–28. 10.1016/j.arth.2007.03.007 Berbari EF, Osmon DR, Lahr B, Eckel-Passow JE, Tsaras G, Hanssen AD, Mabry T, Steckelberg J, Thompson R (2012) The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification. Infect Control Hosp Epidemiol 33:774–781. 10.1086/666641 Zimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. N Engl J Med 351:1645–1654. 10.1056/NEJMra040181 Stoodley P, Sauer K, Davies DG, Costerton JW (2002) Biofilms as complex differentiated communities. Annu Rev Microbiol 56:187–209. 10.1146/annurev.micro.56.012302.160705 Davies DG, Parsek MR, Pearson JP, Iglewski BH, Costerton JW, Greenberg EP (1998) The involvement of cell-to-cell signals in the development of a bacterial biofilm. Science 280:295–298. 10.1126/science.280.5361.295 Lewis K (2007) Persister cells, dormancy and infectious disease. Nat Rev Microbiol 5:48–56. 10.1038/nrmicro1557 Aggarwal VK, Higuera C, Deirmengian G, Parvizi J, Austin MS (2013) Swab cultures are not as effective as tissue cultures for diagnosis of periprosthetic joint infection. Clin Orthop Relat Res 471:3196–3203. 10.1007/s11999-013-2974-y Saleh KJ, Clark CR, Sharkey PF, Goldberg VM, Rand JA, Brown GA (2003) Modes of failure and preoperative evaluation. J Bone Joint Surg Am 85–A(Suppl 1):S21–25. 10.2106/00004623-200300001-00006 Schafer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L (2008) Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 47:1403–1409. 10.1086/592973 Borens O, Helmy N (2016) [Infected osteosynthesis]. Chirurg 87:822–830. 10.1007/s00104-016-0272-4 Metsemakers WJ, Kuehl R, Moriarty TF, Richards RG, Verhofstad MHJ, Borens O, Kates S, Morgenstern M (2018) Infection after fracture fixation: Current surgical and microbiological concepts. Injury 49:511–522. 10.1016/j.injury.2016.09.019 Feihl S, Trampuz A, Renz N (2017) Diagnostik implantatassoziierter Infektionen und Stellenwert der Sonikation. OP-Journal 33:102–106. 10.1055/s-0043-102261 Suda AJ, Kommerell M, Geiss HK, Burckhardt I, Zimmermann S, Zeifang F, Lehner B (2013) Prosthetic infection: improvement of diagnostic procedures using 16S ribosomal deoxyribonucleic acid polymerase chain reaction. Int Orthop 37:2515–2521. 10.1007/s00264-013-2038-7 Trampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, Mandrekar JN, Cockerill FR, Steckelberg JM, Greenleaf JF, Patel R (2007) Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 357:654–663. 10.1056/NEJMoa061588 Mandakhalikar KD, Rahmat JN, Chiong E, Neoh KG, Shen L, Tambyah PA (2018) Extraction and quantification of biofilm bacteria: Method optimized for urinary catheters. Sci Rep 8:8069. 10.1038/s41598-018-26342-3 Karbysheva S, Di Luca M, Butini ME, Winkler T, Schütz M, Trampuz A (2020) Comparison of sonication with chemical biofilm dislodgement methods using chelating and reducing agents: Implications for the microbiological diagnosis of implant associated infection. PLoS ONE 15:e0231389. 10.1371/journal.pone.0231389 Bjerkan G, Witsø E, Bergh K (2009) Sonication is superior to scraping for retrieval of bacteria in biofilm on titanium and steel surfaces in vitro. Acta Orthop 80:245–250. 10.3109/17453670902947457 Niboucha N, Goetz C, Sanschagrin L, Fontenille J, Fliss I, Labrie S, Jean J (2022) Comparative Study of Different Sampling Methods of Biofilm Formed on Stainless-Steel Surfaces in a CDC Biofilm Reactor. Front Microbiol 13:892181. 10.3389/fmicb.2022.892181 Court-Brown CM, McQueen MM (2016) Global Forum: Fractures in the Elderly. J Bone Joint Surg Am 98:e36. 10.2106/JBJS.15.00793 Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J (2008) Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 466:1710–1715. 10.1007/s11999-008-0209-4 Galat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD (2009) Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 91:48–54. 10.2106/JBJS.G.01371 Everhart JS, Altneu E, Calhoun JH (2013) Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 471:3112–3119. 10.1007/s11999-013-2923-9 Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE (2009) Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 24:84–88. 10.1016/j.arth.2009.05.016 Namba RS, Inacio MC, Paxton EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 95:775–782. 10.2106/JBJS.L.00211 Friedman RJ, Hess S, Berkowitz SD, Homering M (2013) Complication rates after hip or knee arthroplasty in morbidly obese patients. Clin Orthop Relat Res 471:3358–3366. 10.1007/s11999-013-3049-9 Laskin RS (2008) The classic: total condylar knee replacement in patients who have rheumatoid arthritis. A ten-year follow-up study. 1990. Clin Orthop Relat Res 466:2589–2596. 10.1007/s11999-008-0462-6 Bongartz T, Halligan CS, Osmon DR, Reinalda MS, Bamlet WR, Crowson CS, Hanssen AD, Matteson EL (2008) Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 59:1713–1720. 10.1002/art.24060 Corvec S, Portillo ME, Pasticci BM, Borens O, Trampuz A (2012) Epidemiology and new developments in the diagnosis of prosthetic joint infection. Int J Artif Organs 35:923–934. 10.5301/ijao.5000168 Holinka J, Windhager R (2016) [Management of prosthetic joint infections]. Orthopade 45:359–373 quiz 374. 10.1007/s00132-016-3247-8 Schmidt HGK, Bühler M (2019) Gelenkinfektionen. Orthopädie und Unfallchirurgie. Springer Berlin Heidelberg, Berlin, Heidelberg, pp 1–27 Font-Vizcarra L, Garcia S, Martinez-Pastor JC, Sierra JM, Soriano A (2010) Blood culture flasks for culturing synovial fluid in prosthetic joint infections. Clin Orthop Relat Res 468:2238–2243. 10.1007/s11999-010-1254-3 Portillo ME, Salvado M, Sorli L, Alier A, Martinez S, Trampuz A, Gomez J, Puig L, Horcajada JP (2012) Multiplex PCR of sonication fluid accurately differentiates between prosthetic joint infection and aseptic failure. J Infect 65:541–548. 10.1016/j.jinf.2012.08.018 Suda AJ, Tinelli M, Beisemann ND, Weil Y, Khoury A, Bischel OE (2017) Diagnosis of periprosthetic joint infection using alpha-defensin test or multiplex-PCR: ideal diagnostic test still not found. Int Orthop 41:1307–1313. 10.1007/s00264-017-3412-7 Collins I, Wilson-MacDonald J, Chami G, Burgoyne W, Vinayakam P, Berendt T, Fairbank J (2008) The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J 17:445–450. 10.1007/s00586-007-0559-8 Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG (2011) New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 469:2992–2994. 10.1007/s11999-011-2102-9 Tables Tab. 1: Shows better diagnostic performance of explant´s surface in the case of antibiotic therapy prior to surgery. antibiotic therapy prior implant removal no antibiotic therapy total p-value biopsy/punction fluid detected bacteria 41 (26.45%) 23 (14.84%) 64 (41.29%) <0.0001 biopsy/punction fluid no detected bacteria 18 (11.61%) 73 (47.10%) 91 (58.71%) Explant´s surface detected bacteria 38 (23.03%) 58 (35.15%) 96 (58.18%) 0.0709 Explant´s surface no detected bacteria 18 (10.91%) 51 (30.91%) 69 (41.82%) Tab. 2: Shows the spectrum of all organisms detected. High-Virulence organisms Multidrug-resistant organisms Low-Virulence organisms Enterobacter cloacae Enterococcus faecalis Enterococcus faecium Escherichia coli Klebsiella aerogenes Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa Staphylococcus aureus Streptococcus agalactiae Streptococcus dysgalacticae equisimilis Methicillin-resistant Staphylococcus aureus Bacillus cereus Bacillus clausii Candida parapsilosis Corynebacterium striatum Corynebacterium urelyticum Corynebacterium spp. Dermabacter hominis Micrococcus luteus Paenibacillus spp. Propionibacterium acnes Staphylococcus capitis Staphylococcus epidermidis Staphylococcus haemolyticus Staphylococcus hominis spp. hominis Staphylococcus saccharolyticus Staphylococcus warneri Stenotrophomonas maltophilia Turicella otitides Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 26 Oct, 2024 Editor assigned by journal 25 Oct, 2024 Submission checks completed at journal 25 Oct, 2024 First submitted to journal 23 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5318175","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":371027934,"identity":"72af1a3b-c559-458e-8eca-a60f262e78cc","order_by":0,"name":"Arnold J Suda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYLCCB2xA4gDzAQbGBmK1JIC1sCWQrIXHgDgt/LPPHnyQUFaX2Hf8zDeJnzts5BjYDx/dgE+LxLm8ZIOEc4cTZ57J3SbZeybNmIEnLe0GXmvO8JhJJLYdSNxwIHebBG/b4cQGCR4zvFrkIVrqEjecf/NM8i8xWgwgWpgTN9zIYZMmyhbDMzzGIL8Yz7zxzNhati3NmI2QX+TO8Bg++FBWJ9t3PvnhzbdtNnL87IeP4fc+EmCRAJFsxCoHAeYPpKgeBaNgFIyCkQMAqdxP7rn0COYAAAAASUVORK5CYII=","orcid":"","institution":"University Hospital Heidelberg","correspondingAuthor":true,"prefix":"","firstName":"Arnold","middleName":"J","lastName":"Suda","suffix":""},{"id":371027935,"identity":"7ee0c905-383b-4af1-8e6d-2e9dabb82a9f","order_by":1,"name":"Thomas Miethke","email":"","orcid":"","institution":"University Medical Centre Mannheim","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Miethke","suffix":""},{"id":371027936,"identity":"fd523183-4107-4272-ae3e-ad14cb0f53f0","order_by":2,"name":"Nadine Landua","email":"","orcid":"","institution":"University Medical Centre Mannheim","correspondingAuthor":false,"prefix":"","firstName":"Nadine","middleName":"","lastName":"Landua","suffix":""},{"id":371027937,"identity":"b517b00c-5036-4580-8c08-0fbd8416e16c","order_by":3,"name":"Udo Obertacke","email":"","orcid":"","institution":"University Medical Centre Mannheim","correspondingAuthor":false,"prefix":"","firstName":"Udo","middleName":"","lastName":"Obertacke","suffix":""}],"badges":[],"createdAt":"2024-10-23 10:38:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5318175/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5318175/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69080214,"identity":"5a811783-e481-41a4-b62f-0eb4014ac4cd","added_by":"auto","created_at":"2024-11-15 11:47:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64243,"visible":true,"origin":"","legend":"\u003cp\u003eThe sterile box for transport of explants (here: a screw).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/754a18cfb08da6212d245f8b.jpg"},{"id":69080220,"identity":"5dfe35b2-62cd-49e5-9bc0-4e0ea96abe9d","added_by":"auto","created_at":"2024-11-15 11:48:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":149016,"visible":true,"origin":"","legend":"\u003cp\u003eBox to grind and transport tissue samples.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/621a7bf88d56efefb2e418c9.jpg"},{"id":69080218,"identity":"71b07bfe-acb1-4188-9649-1d1ac2a4eac7","added_by":"auto","created_at":"2024-11-15 11:47:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":30826,"visible":true,"origin":"","legend":"\u003cp\u003eIndication for implant removal.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/a8ad98fa40d3fa5035361416.png"},{"id":69080216,"identity":"1ccceae9-57cb-4183-b69e-4166222be76a","added_by":"auto","created_at":"2024-11-15 11:47:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":27561,"visible":true,"origin":"","legend":"\u003cp\u003eFindings related to used method.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/aca59b75568177d110f3936c.png"},{"id":69080215,"identity":"925f64b4-c452-4b0a-82ac-f8eef2881afb","added_by":"auto","created_at":"2024-11-15 11:47:59","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":10536,"visible":true,"origin":"","legend":"\u003cp\u003eMost common bacteria detected by all methods and explant´s surface/tissue.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/9d0633aa6786ba8a53fbe42f.png"},{"id":69081034,"identity":"1d089f11-aa53-49a7-832b-4eb248f83bd5","added_by":"auto","created_at":"2024-11-15 11:55:59","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":57513,"visible":true,"origin":"","legend":"\u003cp\u003eShows only the additional detected organisms unraveled by the method.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/0af89c805b0c0e4ed9fd4cbd.png"},{"id":69080219,"identity":"64edcc35-fed2-47da-9ed1-1ffb4139b027","added_by":"auto","created_at":"2024-11-15 11:47:59","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":59447,"visible":true,"origin":"","legend":"\u003cp\u003eShows the single detected organisms particular by each method.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/c419d2b3327013d14b628389.png"},{"id":69081036,"identity":"9b4586c9-0304-4841-9114-a0e56dd452ca","added_by":"auto","created_at":"2024-11-15 11:56:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":774496,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5318175/v1/711725cb-034d-47e5-99f7-6706278bc44c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Advantages in orthopedic implant infection diagnostics by additional analysis of explants","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOrthopedic implants are removed for several reasons such as infection, pain, or mechanical issues. Infection is a main cause but there is a high number of occult and low-grade-infection which are difficult to find. Detection of bacteria after orthopedic implant removal can be influenced by prior antibiotic treatment and the methods used for it. As treatment of orthopedic implant-related infection (OII) is not rare but expensive and harms patient\u0026acute;s quality of life, fast and correct diagnosis and treatment are crucial [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Infection after orthopedic implant implantation can be caused by perioperative contamination, hematogenous infection, or \u003cem\u003eper continuitatem\u003c/em\u003e [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Biofilm on the implant\u0026acute;s surface is often present [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Different classification systems define acute and chronic infections [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There are many known risk factors for OII, such as comorbidities, prolonged operation time, smoking, and revision surgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Coagulase-negative staphylococci such as \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e, part of the natural skin microbiome, are often causal for orthopedic implant-related infections. If they occur in joints or on implants, they are pathogens [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Together with \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, coagulase-negative staphylococci are responsible for 50% of OII [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The other 50% are caused by \u003cem\u003eStreptococci, Enterococci\u003c/em\u003e, Gram-negative rods, anaerobes, \u003cem\u003eCandida\u003c/em\u003e, and rare pathogens [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The presence of low-virulent bacteria such as coagulase-negative staphylococci,, anaerobe \u003cem\u003eCutibacterium (Propionibacterium) acnes\u003c/em\u003e, and Gram-positive \u003cem\u003eCorynebacteria\u003c/em\u003e are often caused by contamination and may lead to a chronic condition and slow development of infection. High-virulent bacteria such as \u003cem\u003eStaphylococcus aureus, Escherichia coli\u003c/em\u003e, and \u003cem\u003eStreptococci\u003c/em\u003e may lead to early and fulminant infection up to sepsis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In 10\u0026ndash;30%, multiple bacteria with a minimum of two pathogens are detected [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Biofilm of the implant\u0026acute;s surface is the main cause of bacterial infection [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A matrix of extra-cellular polymer substances (EPS) surrounds the implant and safes bacteria from antibiotics and the body\u0026acute;s defense cells [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. There are different options for diagnosing OII [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]: detection of bacteria from peri-implant tissue and punction fluid (in joints), whereas swabs don\u0026rsquo;t play a role in diagnostics anymore [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. False-negative results may occur in the case of prior antibiotic treatment [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Three to five tissue samples should be taken from representative locations and incubated for up to ten days [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In the case of the presence of low-virulence pathogens, one single positive result may be interpreted as contamination [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Multiplex-polymerase chain reaction (PCR) may offer new options but are not in extensive use until now [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Detection of the biofilm\u0026acute;s pathogens is promising and sonication of the explant is also used to detect not only planktonic bacteria as in tissue but metabolic inactive bacteria of matrix-secured biofilm but is expensive, not available in all hospitals and challenging in logistics for specimen transport [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The best method for extraction and quantification of biofilm bacteria has not been found yet [\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to evaluate if pathogen-detection by culturing of explants with conventional microbiological methods and without sonication is superior to detection by culture of tissue and punction fluid. Finding a correlation between clinical infection and microbiological results using the methods described was not the aim of this study.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eImplants were removed for different reasons such as infection, irritation, aseptic loosening. Removal of implant, harvesting of tissue from representative areas, and punction fluid in hip, knee, and shoulder joints was performed by the surgeon according to the study protocol. The hospital\u0026acute;s database was used for anonymized patient data, and comorbidities and other risk factors were evaluated.\u003c/p\u003e \u003cp\u003eThe explant was put in a sterile tube (Falcon, Fisher Scientific, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and transferred to the microbiological institute within one hour. The sterile tube was filled with nutrient broth Schaedler Broth\u0026thinsp;+\u0026thinsp;Vit. K3 13 ml (bioM\u0026eacute;rieux SA) at the safety cabinet (HERASAFE2025, Thermo Scientific). The tube was transferred to the incubator HettCube 600 (Hettich) and incubated for ten days. The medium was checked daily and in case of haze seeded to an aerobe agar plate (BIO-RAD Chocolat agar PVS) and Schaedler-Agar (bioM\u0026eacute;rieux SA) for detection of anaerobe. If there was no haze after ten days, the fluid was seeded on the agars as described above and the aerobe agar was incubated for 48 hours in CO\u003csub\u003e2\u003c/sub\u003e-incubator HERAcell240i (Thermo Scientific), the anaerobe plate was placed in an Oxoid AnaeroGen 2.5 l bag (Thermo Scientific) with an Oxoid Resazurin-Anerobic-Indicator (Thermo scientific). In the case of bacterial growth, the bacterium was identified and its antibiotic sensitivity was determined using the automatic Vitek 2 (bioM\u0026eacute;rieux SA) system.\u003c/p\u003e \u003cp\u003eA tissue probe was placed in a sterile tube (ProbeAX, Axon Lab, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) with NaCl and ten small steel balls to chop the tissue in the dispersant IKA ULTRA TURRAX (Tube Drive). The chopped tissue was struck on three aerobe agar plates (blood agar (Fisher Scientific), BIO-RAD Chocolat agar PVS, and Mac-Conkey-Agar (bioM\u0026eacute;rieux SA)) under a safety cabinet (HERASAFE2025). In addition, two anaerobe agar plates were used (Schaedler-Agar (bioM\u0026eacute;rieux SA) and Schaedler-Kanamycin-Vancomycin-Agar (bioM\u0026eacute;rieux SA)). The material was also placed in an anaerobe Schaedler Broth\u0026thinsp;+\u0026thinsp;vit. K3 nutrient broth (13 ml, bioM\u0026eacute;rieux SA), the rest was inoculated in an aerobe Brain Heart Infusion Broth (9 ml, bioM\u0026eacute;rieux SA). Blood agar and Mac-Conkey-Agar were incubated in a HettCube 600 (Hettich) for 24 hours. The chocolate agar was incubated in a CO\u003csub\u003e2\u003c/sub\u003e-incubator HERAcell240i (Thermo Scientific). After 24 hours, aerobe agar plate growth was evaluated. In the case of growth, the bacterium was identified and its antibiotic sensitivity determined. Mac-Conkey-agar was discarded if there was no growth after 24 hours. Chocolate agar was incubated for 10 days in the CO\u003csub\u003e2\u003c/sub\u003e-incubator HERAcell240i (Thermo Scientific) and the case of no growth discarded. Identification of bacteria and antibiotic sensitivity testing was done with Vitek 2 (bioM\u0026eacute;rieux). Anaerobe agar plates were put in 2.5-liter boxes filled with Oxoid AnaeroGen and Oxoid Resazurin-Anaerobe-Indicator (Thermo Scientific) and checked after 48 hours, 4, 7, and 10 days. Aerobe plates were checked after 24 hours, 48 hours, 4, 7 and 10 days. In case of no bacterial growth after 10 days, a final seed in a Schaedler- and chocolate agar was done for 48 hours.\u003c/p\u003e \u003cp\u003eThe punction of fluid was transported in a Falcon tube (Fisher Scientific) and centrifugated using Heraeus Megafuge 16 (Thermo Scientific). With the sediment, a gram stain was performed using Previ Color Gram (bioM\u0026eacute;rieux). Microscopic observation of the Gram preparations was carried out using a Nikon Eclipse Ci microscope. Parallel to the preparation of each Gram preparation, parts of the punctate were inoculated onto three aerobic plates under the safety cabinet (HERASAFE2025, Thermo Scientific): blood agar (Fisher Scientific), chocolate agar (BIO-RAD Chocolat agar PVS) and Mac-Conkey agar (bioM\u0026eacute;rieux SA). Two more anaerobic agar plates were added: Sch\u0026auml;dler agar (bioM\u0026eacute;rieux SA) and Schaedler kanamycin-vancomycin agar (bioM\u0026eacute;rieux SA). Another part of the punctate was added to an anaerobic Schaedler Broth\u0026thinsp;+\u0026thinsp;vit. K3 nutrient broth (13 ml, bioM\u0026eacute;rieux SA) and another part was transferred to an aerobic liquid medium: Brain Heart Infusion Broth (9 ml, bioM\u0026eacute;rieux SA). The blood agar and Mac-Conkey agar were placed in the HettCube 600 incubator (Hettich) for 24 hours. The chocolate agar was placed in the HERAcell240i CO\u003csub\u003e2\u003c/sub\u003e incubator (Thermo Scientific) from the beginning. All aerobic agar plates were read after 24 hours. If aerobic germs had already grown after this period, bacteria were identified and their antibiotic sensitivity determined. The Mac-Conkey agar plate was discarded if no growth was observed after 24 hours. If no growth was seen on the blood agar plate, this plate was also placed in the HERAcell240i CO\u003csub\u003e2\u003c/sub\u003e incubator. The blood agar and the cooked blood agar were then incubated in the CO\u003csub\u003e2\u003c/sub\u003e incubator for up to ten days. If germs had grown during this period, this was also followed by identification and resistance testing. The anaerobic agar plates were incubated as described above. The aerobic plates of the analyzed punction fluids were also checked regularly: After 24 hours, 48 hours, four days, seven days, and ten days respectively. The anaerobic plates were examined for the first time after 48 hours, then also after four days, seven days, and ten days - in the same way as the biopsy specimens. If microbial growth was detected at any of these points in time, bacteria were identified and their antibiotic sensitivity determined as described above.\u003c/p\u003e \u003cp\u003eTo rule out contamination of the sample containers, 19 empty sample containers were explored for bacterial growth. No bacterial growth was detected in any of these sample containers. This ensured that bacteria could only be detected by the respective sample material, i.e. from the metal explant, the tissue sample, or the punctate.\u003c/p\u003e \u003cp\u003e We obtained a positive vote from the local ethical committee (2018 618N MA).\u003c/p\u003e \u003cp\u003eStatistical analysis was performed with the help of the Institute of Medical Statistics/Heinrich-Lanz-Center of Medical Faculty Mannheim with the use of Excel\u0026reg; 2019 (Microsoft) and SAS (Version 9.4 (SAS Institute, Inc., Cary, North Carolina). Shapiro-Wilk-test was used for age distribution, comparison of two different groups was performed with the Mann-Whitney-U-test. More groups were assessed using the Kruskal-Wallis test. The chi\u0026sup2;-test was used for qualitative testing, exact Fisher-test for calculation of contingency tables and significance. α\u0026thinsp;=\u0026thinsp;0.05 was determined as significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween February 2018 and April 2019, 175 consecutive cases (163 patients, 89 females, 86 males, mean age 62.1 years, range 16 to 89) were included in this prospective study with the removal of orthopedic implants in a single university trauma center in Germany. Indication for implant removal was an infection in 64 cases (36.6%), loose implant in 50 cases (28.6%), irritation and painful implant in 33 cases (18.9%), and patient\u0026acute;s wish in 16 cases (9.1%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). 52 patients (29.7%) had been treated with implant-related infection before removal, and another 29 patients (16.6%) needed inpatient treatment for infection. Patients showed several comorbidities: 97 patients (55.4%) had hypertonia, 35 patients (20%) had coronary disease, and 23 patients (13.1%) had diabetes as the main comorbidities. Tumor disease (13.1%), kidney failure (10.9%), obesity (6.9%), osteoporosis (6.3%), and rheumatoid disease (4.6%) were other comorbidities identified. Most patients had more than one comorbidity. 113 patients (64.6%) had no signs of infection in blood cell count (CRP\u0026thinsp;\u0026lt;\u0026thinsp;5mg/l and white blood cells\u0026thinsp;\u0026lt;\u0026thinsp;10000/\u0026micro;l) at the time of surgery. 89 implants (51.4%) have been removed from the femoral region, 42 (24.3%) from the lower leg region, and 18 (10%) in the spine region. 10 implants (5.8%) were removed from the humerus, 8 (4.6%) from the forearm and 6 (3.5%) from the pelvis. In 2 cases, the exact region was unclear due to unclear documentation of removal between the two regions. The authors decided to define the region according to the surgical report. In 148 cases (84.6%), no bacteria could be detected before implant removal, in 61 cases (34.9%), antibiotic treatment was administered before surgery (Table\u0026nbsp;1). 25 patients (14.3%) had one revision surgery before implant removal, and another 32 patients (18.3%) had two or more surgeries. 30 (17.1%) of 175 specimens could not be fully evaluated according to the study protocol (155 cases with tissue/punction fluid, 165 cases with explants): in 10 cases, the transport box of the explant was damaged and in 20 cases, punction fluid was not enough for evaluation or not taken so the comparison was impossible. Overall, 145 cases were included in the study with explant, tissue, and punction fluid.\u003c/p\u003e \u003cp\u003eIn 46 cases (31.7%), no bacteria could be detected. 71 of 145 cases (49.0%) showed the same bacteria in both tissue and explant\u0026acute;s surface. With tissue and punction fluid alone, bacteria could be detected in 91 cases (62.8%), on explant\u0026acute;s surface alone, bacteria could be detected in 96 cases (66.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, tissue/punction fluid compared to explant\u0026acute;s surface). In 41 cases (28.3%), bacteria could only be detected from the explant\u0026acute;s surface whereas this was only the case in 11 cases (7.6%) of tissue/punction fluid (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, explant\u0026acute;s surface compared to tissue/punction fluid). In another 22 cases, additional bacteria could be detected from explant\u0026acute;s surface or tissue/punction fluid (11 and 11, respectively). 25 cases (36.5%) showed same bacteria throughout all examination methods: in 123 cases (71\u0026thinsp;+\u0026thinsp;41\u0026thinsp;+\u0026thinsp;11\u0026thinsp;=\u0026thinsp;84.83%), detection of pathogens from explant\u0026acute;s surface was equal or superior compared to tissue and punction fluid (93 cases, 71\u0026thinsp;+\u0026thinsp;11\u0026thinsp;+\u0026thinsp;11\u0026thinsp;=\u0026thinsp;64.14%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, explant\u0026acute;s surface compared to tissue/punction fluid).\u003c/p\u003e \u003cp\u003eThe spectrum of organisms detected is provided in Table\u0026nbsp;2. \u003cem\u003eStaphylococcus epidermidis, S. aureus and E. faecalis\u003c/em\u003e were most commonly detected by all diagnostic methods used (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows only the additional detected organisms unraveled by the method used in patients with multiple bacteria detected, Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e shows the single detected organisms particular by each method. Age, sex, reason for surgery, type of implant or hypertonia, and original diagnosis for implantation or other comorbidities did not show statistically significant influences on results (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05, respectively). In cases with or without antibiotic treatment before surgery, bacteria could be detected in tissue/Punction fluid in 11.6% and 14.8% in cases without antibiotic treatment (Table\u0026nbsp;1, p\u0026thinsp;=\u0026thinsp;0.0001). In cases with or without antibiotic treatment before surgery, bacteria could be detected in explant\u0026acute;s surface in 23.0% and 35.2% (p\u0026thinsp;=\u0026thinsp;0.071). In this collective, antibiotic treatment before surgery had a statistically significant influence of detection of bacteria of tissue or punction fluid but not of explant\u0026acute;s surface. The differences in detection between tissue/punction fluid and explants\u0026acute;s surfacewere statistically significant (p\u0026thinsp;=\u0026thinsp;0.0001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the detection of bacteria of orthopedic explant\u0026acute;s surface showed significantly higher sensitivity (84.8%) compared to tissues or punction fluid (64.1%). Treatment of orthopedic implant-related infections is challenging for both patient and surgeon as well as expensive [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Fast and correct detection of bacteria causing the infection is crucial for correct treatment, independent of age or comorbidities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the reasons for the implantation and explantation of orthopedic implants were multifaceted, similar to other studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this study, no differences in the detection of bacteria were seen regarding comorbidities [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37 CR38 CR39 CR40 CR41 CR42\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. A broad range of pathogens could be identified, the spectrum was similar to other studies: In a study of Corvec et al., coagulase-negative Staphylococci were identified as the most common pathogens in OII [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Multiple bacteria are present from 10 to 30%, revision surgery and longer operation times are suspected main reasons [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our study, \u003cem\u003eCorynebacterium\u003c/em\u003e was identified as a rare pathogen in OII, similar to Holinka et al. [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. \u003cem\u003eMicrococcus luteus\u003c/em\u003e and \u003cem\u003eStenotrophomonas maltophilia\u003c/em\u003e were detected quite often in the explant\u0026acute;s biofilm. The presence of these was described before in patients with rheumatoid disease and immune-suppressive therapy [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. \u003cem\u003eMicrococcus luteus\u003c/em\u003e was described as a non-pathogenic bacteria but not previously discussed as a pathogen in OII. It remains uncertain if the presence of \u003cem\u003eMicrococcus luteus\u003c/em\u003e on the implant\u0026acute;s surface has any clinical impact. No pathogens could be detected in many patients in our collective because these patients received orthopedic implant removal for other reasons than infection. Linking clinical findings and the presence of infection to microbiological diagnostic methods was not the aim of this study. Font-Vizcarra et al. showed that swabs are not suitable for OII diagnostics, their only advantage is the low cost [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Trampuz et al. compared the diagnostics of sonication fluid with tissue and showed higher sensitivity compared to tissue (79%, and 61%, respectively) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Because of costs and the complexity of transport and procedure, sonication is not available in all hospitals [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Portillo et al. showed higher sensitivity of multiplex-PCR compared to sonication but this procedure is also expensive and did not become standard procedure so far as there is a high risk of contamination and false positive results [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. In a prior study, the author of this study showed a high negative but low positive predictive value in OII \u0026ndash; diagnostics using multiplex-PCR [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Today, the gold standard for OII diagnostics remains 3 to 5 tissue samples and conventional microbiological methods [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. More samples could lead to more false-positive results because of contamination [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Reasons for negative results may be prolonged transport to the microbiological lab, too short incubation time, prior antibiotic therapy, or low-virulent pathogens [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In our study, all samples were transported immediately within hours to the lab and all samples were incubated for 10 days. Low-virulent and slow-growing pathogens can be detected safely using this technique [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Sch\u0026auml;fer et al. described only 74% of bacteria detection in the first seven days, and other bacteria up to ten days, so we decided on ten days in our study [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We could see a statistical significance of prior antibiotic therapy and diagnostic results of tissue and punction fluid in our collective, similar to Flesch et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our results support the theory that biofilm diagnostic is superior to tissue. In 35.9%, we detected more pathogens in biofilm compared to tissue and punction fluid, which was seen before [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. One reason may be the biofilm protection for antibiotic therapy which is not present in tissue samples [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Antibiotic treatment should be initiated immediately in case of acute infection and not delayed until samples can be taken which is not recommended in chronic infection [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In 15.2% (22 cases), pathogens could only be shown in tissue or punction fluid. Contamination with skin or absence of biofilm may be the main reason for this as published before [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In 84.8%, the explant\u0026acute;s surface showed pathogens \u0026ndash; in 64.1%, tissue and punction fluid showed pathogens - in 49.0%, both explant\u0026acute;s surface and tissue showed pathogens (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively) which supports our hypothesis that diagnostic of explant\u0026acute;s surface fluid is superior to tissue and/or punction fluid. Instead of up to 5 samples, one sample of explant\u0026acute;s surface may be enough for safe and correct diagnostics which reduces costs and spares resources [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has several limitations: First, this study was performed in a single center in Germany. An international multiple-center study could lead to the detection of different pathogens and different results. Second, the study sample was relatively small, a larger sample size could also lead to different results. Third, co-morbidities were evaluated according to electronic patient data: missing or wrong information may have influenced our results with no statistically significant influence of any co-morbidity. Fourth, no comparison to other methods such as sonication or PCR and no correlation to clinical infection was performed: this could be the topic of the next study in a multi-centric setting. Fifth, employees of the microbiological institute knew about this study \u0026ndash; this may have biased the results or the methods of their work but this was mandatory due to the ethical committee vote. An advantage was the diagnostics at one single center with the same procedures and machines. Sixth, the pooling of five tissue samples may also reduce costs but would not identify as many pathogens as explant\u0026acute;s surface. Lastly, only English and German publications were included in the literature research.\u003c/p\u003e \u003cp\u003eIn summary, our study supports the hypothesis that pathogen diagnosis of orthopedic explant\u0026acute;s surface using incubation of the transport fluid is superior compared to tissue samples. Now that this method is proven to be functional, cheap, and safe, future multiple-center studies considering the clinical status as well may support the findings of our present study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompliance with Ethical Standards\u003c/h2\u003e \u003cp\u003eHuman Ethics and Consent to Participate declarations: not applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Nadine Landua and Arnold Suda. The first draft of the manuscript was written by Nadine Landua and Arnold J Suda and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.Conceptualization: Arnold J Suda; Methodology: Thomas Miethke, Udo Obertacke, Arnold J Suda; Formal analysis and investigation: Nadine Landua; Writing - original draft preparation: Nadine Landua and Arnold J Suda; Writing - review and editing: Arnold J Suda, Thomas Miethke, Udo Obertacke; Resources: Thomas Miethke, Arnold J Suda; Supervision: Arnold J Suda, Thomas Miethke, Udo Obertacke.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDarouiche RO (2004) Treatment of infections associated with surgical implants. N Engl J Med 350:1422\u0026ndash;1429. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMra035415\u003c/span\u003e\u003cspan address=\"10.1056/NEJMra035415\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRenz N, Muller M, Perka C, Trampuz A (2016) [Implant-associated infections - Diagnostics]. Chirurg 87:813\u0026ndash;821. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00104-016-0234-x\u003c/span\u003e\u003cspan address=\"10.1007/s00104-016-0234-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArciola CR, Campoccia D, Ehrlich GD, Montanaro L (2015) Biofilm-based implant infections in orthopaedics. Adv Exp Med Biol 830:29\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-319-11038-7_2\u003c/span\u003e\u003cspan address=\"10.1007/978-3-319-11038-7_2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurtz SM, Lau E, Watson H, Schmier JK, Parvizi J (2012) Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 27:61\u0026ndash;65 e61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.arth.2012.02.022\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2012.02.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRenz N, Perka C, Trampuz A (2016) [Management of periprosthetic infections of the knee]. Orthopade 45:65\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00132-015-3217-6\u003c/span\u003e\u003cspan address=\"10.1007/s00132-015-3217-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWinkler T, Trampuz A, Hardt S, Janz V, Kleber C, Perka C (2014) [Periprosthetic infection after hip arthroplasty]. Orthopade 43:70\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00132-013-2132-y\u003c/span\u003e\u003cspan address=\"10.1007/s00132-013-2132-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlesch I, Arnscheidt C, Ihle C (2017) Sp\u0026auml;tinfekt in der Endoprothetik. OP-JOURNAL 33:142\u0026ndash;148\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrampuz A, Zimmerli W (2006) Diagnosis and treatment of infections associated with fracture-fixation devices. Injury 37 Suppl 2S59\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.injury.2006.04.010\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2006.04.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerka C, Haas N (2011) [Periprosthetic infection]. Chirurg 82:218\u0026ndash;226. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00104-010-2014-3\u003c/span\u003e\u003cspan address=\"10.1007/s00104-010-2014-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarrett L, Atkins B (2014) The clinical presentation of prosthetic joint infection. J Antimicrob Chemother 69(Suppl 1):i25\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jac/dku250\u003c/span\u003e\u003cspan address=\"10.1093/jac/dku250\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerli W (2014) Clinical presentation and treatment of orthopaedic implant-associated infection. J Intern Med 276:111\u0026ndash;119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/joim.12233\u003c/span\u003e\u003cspan address=\"10.1111/joim.12233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBozic KJ, Lau E, Kurtz S, Ong K, Berry DJ (2012) Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop Relat Res 470:130\u0026ndash;137. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-011-2043-3\u003c/span\u003e\u003cspan address=\"10.1007/s11999-011-2043-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen JY, Lo NN, Chong HC, Bin Abd Razak HR, Pang HN, Tay DK, Chia SL, Yeo SJ (2016) The influence of body mass index on functional outcome and quality of life after total knee arthroplasty. Bone Joint J 98\u0026ndash;B:780\u0026ndash;785. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/0301-620X.98B6.35709\u003c/span\u003e\u003cspan address=\"10.1302/0301-620X.98B6.35709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeersman G, Laskin R, Davis J, Peterson M (2001) Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res :15\u0026ndash;23\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowsey MM, Choong PF (2009) Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res 467:1577\u0026ndash;1581. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-008-0551-6\u003c/span\u003e\u003cspan address=\"10.1007/s11999-008-0551-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL (2012) Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty 27:726\u0026ndash;729e721. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.arth.2011.09.013\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2011.09.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH (2007) Does excessive anticoagulation predispose to periprosthetic infection? J Arthroplasty 22:24\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.arth.2007.03.007\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2007.03.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerbari EF, Osmon DR, Lahr B, Eckel-Passow JE, Tsaras G, Hanssen AD, Mabry T, Steckelberg J, Thompson R (2012) The Mayo prosthetic joint infection risk score: implication for surgical site infection reporting and risk stratification. Infect Control Hosp Epidemiol 33:774\u0026ndash;781. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1086/666641\u003c/span\u003e\u003cspan address=\"10.1086/666641\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmerli W, Trampuz A, Ochsner PE (2004) Prosthetic-joint infections. N Engl J Med 351:1645\u0026ndash;1654. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMra040181\u003c/span\u003e\u003cspan address=\"10.1056/NEJMra040181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoodley P, Sauer K, Davies DG, Costerton JW (2002) Biofilms as complex differentiated communities. Annu Rev Microbiol 56:187\u0026ndash;209. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1146/annurev.micro.56.012302.160705\u003c/span\u003e\u003cspan address=\"10.1146/annurev.micro.56.012302.160705\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavies DG, Parsek MR, Pearson JP, Iglewski BH, Costerton JW, Greenberg EP (1998) The involvement of cell-to-cell signals in the development of a bacterial biofilm. Science 280:295\u0026ndash;298. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1126/science.280.5361.295\u003c/span\u003e\u003cspan address=\"10.1126/science.280.5361.295\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis K (2007) Persister cells, dormancy and infectious disease. Nat Rev Microbiol 5:48\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nrmicro1557\u003c/span\u003e\u003cspan address=\"10.1038/nrmicro1557\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAggarwal VK, Higuera C, Deirmengian G, Parvizi J, Austin MS (2013) Swab cultures are not as effective as tissue cultures for diagnosis of periprosthetic joint infection. Clin Orthop Relat Res 471:3196\u0026ndash;3203. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-013-2974-y\u003c/span\u003e\u003cspan address=\"10.1007/s11999-013-2974-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaleh KJ, Clark CR, Sharkey PF, Goldberg VM, Rand JA, Brown GA (2003) Modes of failure and preoperative evaluation. J Bone Joint Surg Am 85\u0026ndash;A(Suppl 1):S21\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/00004623-200300001-00006\u003c/span\u003e\u003cspan address=\"10.2106/00004623-200300001-00006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchafer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L (2008) Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 47:1403\u0026ndash;1409. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1086/592973\u003c/span\u003e\u003cspan address=\"10.1086/592973\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorens O, Helmy N (2016) [Infected osteosynthesis]. Chirurg 87:822\u0026ndash;830. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00104-016-0272-4\u003c/span\u003e\u003cspan address=\"10.1007/s00104-016-0272-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMetsemakers WJ, Kuehl R, Moriarty TF, Richards RG, Verhofstad MHJ, Borens O, Kates S, Morgenstern M (2018) Infection after fracture fixation: Current surgical and microbiological concepts. Injury 49:511\u0026ndash;522. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.injury.2016.09.019\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2016.09.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeihl S, Trampuz A, Renz N (2017) Diagnostik implantatassoziierter Infektionen und Stellenwert der Sonikation. OP-Journal 33:102\u0026ndash;106. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0043-102261\u003c/span\u003e\u003cspan address=\"10.1055/s-0043-102261\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuda AJ, Kommerell M, Geiss HK, Burckhardt I, Zimmermann S, Zeifang F, Lehner B (2013) Prosthetic infection: improvement of diagnostic procedures using 16S ribosomal deoxyribonucleic acid polymerase chain reaction. Int Orthop 37:2515\u0026ndash;2521. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00264-013-2038-7\u003c/span\u003e\u003cspan address=\"10.1007/s00264-013-2038-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR, Mandrekar JN, Cockerill FR, Steckelberg JM, Greenleaf JF, Patel R (2007) Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 357:654\u0026ndash;663. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa061588\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa061588\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMandakhalikar KD, Rahmat JN, Chiong E, Neoh KG, Shen L, Tambyah PA (2018) Extraction and quantification of biofilm bacteria: Method optimized for urinary catheters. Sci Rep 8:8069. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-018-26342-3\u003c/span\u003e\u003cspan address=\"10.1038/s41598-018-26342-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarbysheva S, Di Luca M, Butini ME, Winkler T, Sch\u0026uuml;tz M, Trampuz A (2020) Comparison of sonication with chemical biofilm dislodgement methods using chelating and reducing agents: Implications for the microbiological diagnosis of implant associated infection. PLoS ONE 15:e0231389. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0231389\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0231389\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBjerkan G, Wits\u0026oslash; E, Bergh K (2009) Sonication is superior to scraping for retrieval of bacteria in biofilm on titanium and steel surfaces in vitro. Acta Orthop 80:245\u0026ndash;250. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/17453670902947457\u003c/span\u003e\u003cspan address=\"10.3109/17453670902947457\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiboucha N, Goetz C, Sanschagrin L, Fontenille J, Fliss I, Labrie S, Jean J (2022) Comparative Study of Different Sampling Methods of Biofilm Formed on Stainless-Steel Surfaces in a CDC Biofilm Reactor. Front Microbiol 13:892181. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fmicb.2022.892181\u003c/span\u003e\u003cspan address=\"10.3389/fmicb.2022.892181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCourt-Brown CM, McQueen MM (2016) Global Forum: Fractures in the Elderly. J Bone Joint Surg Am 98:e36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.15.00793\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.15.00793\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J (2008) Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 466:1710\u0026ndash;1715. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-008-0209-4\u003c/span\u003e\u003cspan address=\"10.1007/s11999-008-0209-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalat DD, McGovern SC, Larson DR, Harrington JR, Hanssen AD, Clarke HD (2009) Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 91:48\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.G.01371\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.G.01371\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEverhart JS, Altneu E, Calhoun JH (2013) Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 471:3112\u0026ndash;3119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-013-2923-9\u003c/span\u003e\u003cspan address=\"10.1007/s11999-013-2923-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE (2009) Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty 24:84\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.arth.2009.05.016\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2009.05.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNamba RS, Inacio MC, Paxton EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 95:775\u0026ndash;782. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.L.00211\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.L.00211\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriedman RJ, Hess S, Berkowitz SD, Homering M (2013) Complication rates after hip or knee arthroplasty in morbidly obese patients. Clin Orthop Relat Res 471:3358\u0026ndash;3366. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-013-3049-9\u003c/span\u003e\u003cspan address=\"10.1007/s11999-013-3049-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaskin RS (2008) The classic: total condylar knee replacement in patients who have rheumatoid arthritis. A ten-year follow-up study. 1990. Clin Orthop Relat Res 466:2589\u0026ndash;2596. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-008-0462-6\u003c/span\u003e\u003cspan address=\"10.1007/s11999-008-0462-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBongartz T, Halligan CS, Osmon DR, Reinalda MS, Bamlet WR, Crowson CS, Hanssen AD, Matteson EL (2008) Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 59:1713\u0026ndash;1720. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/art.24060\u003c/span\u003e\u003cspan address=\"10.1002/art.24060\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorvec S, Portillo ME, Pasticci BM, Borens O, Trampuz A (2012) Epidemiology and new developments in the diagnosis of prosthetic joint infection. Int J Artif Organs 35:923\u0026ndash;934. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5301/ijao.5000168\u003c/span\u003e\u003cspan address=\"10.5301/ijao.5000168\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolinka J, Windhager R (2016) [Management of prosthetic joint infections]. Orthopade 45:359\u0026ndash;373 quiz 374. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00132-016-3247-8\u003c/span\u003e\u003cspan address=\"10.1007/s00132-016-3247-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt HGK, B\u0026uuml;hler M (2019) Gelenkinfektionen. Orthop\u0026auml;die und Unfallchirurgie. Springer Berlin Heidelberg, Berlin, Heidelberg, pp 1\u0026ndash;27\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFont-Vizcarra L, Garcia S, Martinez-Pastor JC, Sierra JM, Soriano A (2010) Blood culture flasks for culturing synovial fluid in prosthetic joint infections. Clin Orthop Relat Res 468:2238\u0026ndash;2243. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-010-1254-3\u003c/span\u003e\u003cspan address=\"10.1007/s11999-010-1254-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePortillo ME, Salvado M, Sorli L, Alier A, Martinez S, Trampuz A, Gomez J, Puig L, Horcajada JP (2012) Multiplex PCR of sonication fluid accurately differentiates between prosthetic joint infection and aseptic failure. J Infect 65:541\u0026ndash;548. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jinf.2012.08.018\u003c/span\u003e\u003cspan address=\"10.1016/j.jinf.2012.08.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuda AJ, Tinelli M, Beisemann ND, Weil Y, Khoury A, Bischel OE (2017) Diagnosis of periprosthetic joint infection using alpha-defensin test or multiplex-PCR: ideal diagnostic test still not found. Int Orthop 41:1307\u0026ndash;1313. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00264-017-3412-7\u003c/span\u003e\u003cspan address=\"10.1007/s00264-017-3412-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollins I, Wilson-MacDonald J, Chami G, Burgoyne W, Vinayakam P, Berendt T, Fairbank J (2008) The diagnosis and management of infection following instrumented spinal fusion. Eur Spine J 17:445\u0026ndash;450. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00586-007-0559-8\u003c/span\u003e\u003cspan address=\"10.1007/s00586-007-0559-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG (2011) New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 469:2992\u0026ndash;2994. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-011-2102-9\u003c/span\u003e\u003cspan address=\"10.1007/s11999-011-2102-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTab. 1: Shows better diagnostic performance of explant\u0026acute;s surface in the case of antibiotic therapy prior to surgery.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eantibiotic therapy prior implant removal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eno antibiotic therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e\u003cstrong\u003etotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ebiopsy/punction fluid\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003edetected bacteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e41 (26.45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e23 (14.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e64 (41.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 14%;\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ebiopsy/punction fluid\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eno detected bacteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e18 (11.61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e73 (47.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e91 (58.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExplant\u0026acute;s surface\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003edetected bacteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e38 (23.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e58 (35.15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e96 (58.18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 14%;\"\u003e\n \u003cp\u003e0.0709\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExplant\u0026acute;s surface\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eno detected bacteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24%;\"\u003e\n \u003cp\u003e18 (10.91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20%;\"\u003e\n \u003cp\u003e51 (30.91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14%;\"\u003e\n \u003cp\u003e69 (41.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTab. 2: Shows the spectrum of all organisms detected.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3398%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh-Virulence organisms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.8301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultidrug-resistant organisms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.8301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow-Virulence organisms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.3398%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEnterobacter cloacae\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEnterococcus faecalis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEnterococcus faecium\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEscherichia coli\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eKlebsiella aerogenes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eKlebsiella pneumoniae\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProteus mirabilis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePseudomonas aeruginosa\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaphylococcus aureus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStreptococcus agalactiae\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStreptococcus dysgalacticae\u003c/p\u003e\n \u003cp\u003eequisimilis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.8301%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMethicillin-resistant Staphylococcus aureus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.8301%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBacillus cereus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBacillus clausii\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCandida parapsilosis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCorynebacterium striatum\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCorynebacterium urelyticum\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCorynebacterium spp.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDermabacter hominis\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMicrococcus luteus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePaenibacillus spp.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePropionibacterium acnes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaphylococcus capitis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaphylococcus epidermidis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaphylococcus haemolyticus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaphylococcus hominis spp. hominis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaphylococcus saccharolyticus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaphylococcus warneri\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStenotrophomonas maltophilia\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTuricella otitides\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"orthopaedic implant infection diagnostics, implant surface, implant removal","lastPublishedDoi":"10.21203/rs.3.rs-5318175/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5318175/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose\u003c/p\u003e\n\u003cp\u003eImplant-associated infections are the most challenging complication in orthopedics and trauma surgery as they often lead to long courses of illness and are a financial burden for the healthcare system. There is a need for fast, simple, and cheap identification of pathogens but the ideal detection method was not found yet. The work aims to test whether the detection of pathogens \u0026nbsp;culturing the removed implant is more successful than from simultaneously taken tissue samples or punction fluid.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eImplants were removed due to infection, irritation, or loosening. Tissue samples and joint fluids were processed for bacterial growth in sterile conditions. Samples were incubated and checked for growth. Bacterial identification and antibiotic sensitivity testing were performed. Data were anonymized, and statistical analysis was done using Excel and SAS, employing tests like Shapiro-Wilk, Mann-Whitney-U, and Kruskal-Wallis. Ethical approval was obtained for this \u0026nbsp;study.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eBetween February 2018 and April 2019, a total of 163 patients (175 cases) underwent orthopedic implant removal for various reasons. 30 cases were not usable or analyzable due to missing or damaged reference material, so 145 cases could be evaluated due to study protocol.\u003c/p\u003e\n\u003cp\u003eThe range of detected bacteria was as expected and included low-virulent bacteria such as \u003cem\u003eMicrococcus luteus\u003c/em\u003eand \u003cem\u003eCorynebacteria\u003c/em\u003e. Pathogen detection by culture of the the explant´s was more sensitive (84.83%) than pathogen detection from tissue samples and punction fluid (64.14%, p\u0026lt;0.0001). Comorbidities did not play any role in the quality of detection but prior antibiotic treatment did influence the results of tissue diagnostics.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eThis study showed with a higher frequency of bacterial detection of orthopedic explant´s surface compared to tissue samples or punction fluid. This may reduce the number of samples and cost but enhances the quality of orthopedic implant-related infection diagnostics.\u003c/p\u003e","manuscriptTitle":"Advantages in orthopedic implant infection diagnostics by additional analysis of explants","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-15 11:47:54","doi":"10.21203/rs.3.rs-5318175/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2024-10-26T21:17:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-26T00:26:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-26T00:25:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Orthopaedics","date":"2024-10-23T10:22:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-orthopaedics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [International Orthopaedics](https://link.springer.com/journal/264)","snPcode":"264","submissionUrl":"https://submission.springernature.com/new-submission/264/3","title":"International Orthopaedics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1f58a45a-5d23-43af-9dd5-13587dfd5283","owner":[],"postedDate":"November 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T00:38:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-15 11:47:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5318175","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5318175","identity":"rs-5318175","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}